Interview with Dr. Schechter about Mind-Body Medicine
An Interview with David Schechter, MD about his practice of mindbody medicine.
How is your practice different than the average doctor?
I see quite a few patients who specifically come to me because they have a sense that emotional tension is playing a role in their back pain (or other conditions) and look to me to confirm this impression and to teach them a novel way to overcome this.
Are there any differences in the information you collect on your patients?
Patients begin by coming to the office and filling out the usual forms (patient info, treatment agreement) found in any doctor’s office. There’s a pain diagram, where they graphically describe their pain, but this is typical in the pain management field. Quite atypical is a 7-item questionnaire that asks them if they can relate their pain to tension and stress, if they have ever suffered other illnesses that may be stress-related (e.g. irritable bowel syndrome, tension headaches, TMJ), and asks about personality characteristics.
How are patients referred to you?
Some in the typical ways, such as a referral from another local doctor, physical therapist, or a patient. However, many patients have learned about my work from the internet, from my writings, and via referral from Dr. Sarno's books and prior to his retirement (and death) from his office.
What does the consultation consist of?
I ask the patient to tell me about their problem in as much detail as they would like; I urge them to take their time. I typically hear from people that the pain has lasted one to twenty years, or even more. They have usually tried a variety of treatments and therapies before seeing me. They have tried medication, physical and/or chiropractic therapy, often seen a primary care doctor and one or more specialists (orthopedic, neurology, rheumatology). Many have had acupuncture, massage, or homeopathic remedies. Most have had x-rays. Quite a number have also had an MRI. The vast majority has been told that their condition is not amenable to surgery, although some have tried epidural injections or had some kind of back surgery in the past.
Are these people able to function after all this pain?
A significant number of these individuals have had progressive deterioration in their ability to be functional and active. These individuals may be limiting their recreational pursuits and/or modifying their work or family life significantly due to pain and due to fear of injury. Others are quite active, but have intermittent bouts of severe painful attacks and live in fear of these attacks. Some people have constant, low to intermediate grade discomfort. Again, nearly everyone has seen a bunch of other practitioners and tried a variety of treatments. The success of these treatments has been short-term, at best, or ineffective, at worst.
What is your goal in speaking with your patients?
When I talk to a patient, I try to listen very closely. We’re taught in medical school that the history is usually 90% of the diagnosis. But most doctors rush through their day, quickly examine patients, and rely on lab tests too much. I listen to my patient’s story; it has a lot to tell me about his condition and about him. I listen for a patient’s fears and preconceptions about his pain. I encourage him to make connections between painful episodes and emotional issues. I allow forty-five minutes for a new patient consultation for this purpose. I may take longer, if needed, to understand the patient.
What misconceptions do people have about their pain?
Many people relate their pain purely to physical incidents or wonder if they "slept wrong". I find that it helps to review some of these subtle issues at the end of their history. I try to help them to understand that the onset of pain may have psychological as well as physical triggers and that their psychological issues may be more important! Of course I ask about other medical problems, allergies, and medications. I also ask her to elaborate from the questionnaire about her relevant personality characteristics. I explain that the very personality characteristics (responsible, perfectionism, "hard-on-yourself", and do-gooder) that contributed to success in their professional or personal life can carry a burden of tension with them. I also clarify any other stress-related illnesses they may have suffered from in the past and determine when they ended. It’s not unusual for a patient’s headaches to disappear at around the time their back pain started, or vice versa!
Is a physical examination important, as well?
I do a careful neuro-musculo-skeletal examination including range of motion, strength testing, reflexes, sensation, and touch the areas that the patient has pain, looking for tenderness and spasm. I also carefully probe eight areas on their back and neck that help me to diagnose their condition. These spots on their trapezius (muscle between neck and shoulders), quadratus lumborum (low back above hips), gluteus (outer buttocks), and iliotibial band (outer, upper leg) are often tender in people with a mind body back condition. These locations overlap with some of the fibromyalgia tender points, of which there are 19, not eight.
Do you look at or order x-rays? What about MRI scans?
I carefully review any x-rays, MRI scans, or reports that patients bring in. If they have a small bulging disc, I evaluate where it is bulging, whether it is pushing on a nerve, and whether their pain matches the anatomical area that should be hurting if the disc were causing the pain. Many of the patients have more than one area of pain (and tenderness), or the pain moves around, and this makes it easier to know that an isolated disc (or even two) is unlikely to be the sole or important cause of the pain.
If the findings confirm a mind body condition, what do you diagnose?
For those patients who have most of the above findings (failure of multiple treatments, characteristic personality, exacerbation with tension, tender points, no localizable structural lesion, perhaps migrating pain), I diagnose and treat them forTension Myoneural or Myositis Syndrome (TMS). The ‘tension’ refers to the emotional tension that underlies the condition and the tightness in the muscles. The ‘myositis’ or "myoneural" refers to muscles and nerves and that this is a soft tissue condition. The ‘syndrome’ refers to the fact that symptoms from TMS can be varied and variable.
Are there other names for this condition? Are there similar conditions being treated by other medical doctors?
Dr. John Sarno coined this name over thirty five years ago. While the term "TMS" is not widely known in the medical community, I accord Dr. Sarno the respect he deserves for his innovative work by using the name TMS, rather than some of the other possibilities—myofascial pain syndrome, fibromyalgia variant, lumbar myofasciitis, lumbar syndrome, chronic pain syndrome, etc. Many of these are misused or have been appropriated by other treatment philosophies and are therefore not useful in getting patients to break away from their existing beliefs about their pain and getting them to a mindset where the pain can go away.
How do you treat this condition?
First, I must be clear to the patient what their diagnosis is and why I have made it. I explain to them, as I’ve explained to you above, how I’ve come to the diagnosis in their particular case. Many are familiar with the diagnosis from having reviewed my web site (www.MindBodyMedicine.com) or other materials on the subject (e.g. my books, Think Away Your Pain and The MindBody Workbook). I explain to them why their other attempts at treatment have failed and why a new approach is needed. I emphasize that belief in this diagnosis and commitment to the treatment program is a requirement for success. This treatment is not something I administer to them, like a drug or an injection. My role is as a guide, a mentor, and a doctor in the original Latin sense of the word ‘doctore’—a teacher.
I explain that connecting pain to emotions is crucial. I describe my educational program to them and encourage them to keep a daily journal of emotions. We talk about their fears, with my recall of what they said to me earlier in the visit often crucial in personalizing this. They share their hopes and fears about recovery. I describe the importance of gradually resuming activities that have been prohibited by other practitioners or from which they have restricted themselves due to pain or fear or injury. I answer any and all questions that may arise and encourage them to email me with additional questions that may come up. I also remind them that doubt is a common issue in treatment and give them some ideas on how to deal with doubt. I remind them to "think psychologically, not physically".
How are people able to follow-through with the insight and knowledge they learn in the office visit?
Patients often leave with a set of CD’s on this subject, perhaps a DVD, and a workbook. Some patients are referred to specially trained psychotherapists in the Los Angeles area who collaborate with me on treating this condition.
Are there follow-up visits?
I typically recommend a follow-up visit at about three weeks after the initial consultation and for out-of-town patients I will do an email or telephone call follow-up. If the patient is doing great, my three-week recheck may focus on helping the patient to understand and build on her clinical improvement. I may encourage specific types of physical activity, more vigorous exercise, or longer walks. For patients who are not improving significantly at three weeks, I explore any hesitation or difficulty in accepting the diagnosis that they may be experiencing. We talk about how and why the diagnosis was made and try to link this to any emotional issues that they are aware of, perhaps from journaling or reflecting on the subject. Finally, I consider a referral to a psychologist, where appropriate, to more deeply delve into some of these matters.
What feedback do you get from patients?
Every month I get thank you calls, emails, and letters from patients who have succeeded in this approach after having failed many different treatments for their back and neck pain. This, in and of itself, is highly motivating and satisfying to me. The occasional "miracle" cure where someone with twenty years of pain and no ability to exercise is suddenly able to run or swim every day and feels wonderful is a further boost encouragement to my work. I've published a few papers in this area and despite a difficult group of chronic pain patients-- very high success rates.
Thank you Dr. Schechter
You are most welcome.
For an interview with Dr. Schechter about his personal TMS experience and his background with Dr. John E. Sarno:
Dr. David Schechter